🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-09-03 09:43:56

Transcript

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                                             <tbody><tr><td id="fragmentid_1"><div><p><strong class="Doctor">Doctor</strong>: Good morning, Mrs. Sharma. It's good to see you again. How have you been feeling since our last session?</p></div></td></tr><tr><td id="fragmentid_2"><div><p><strong class="Patient">Patient</strong>: Good morning, doctor. Honestly, not great. The pain in my left hand has gotten worse. It's sharp, constant, and sometimes it feels like it's burning from the inside. And I don't know how to say this. I've started seeing things that aren't there.</p></div></td></tr><tr><td id="fragmentid_3"><div><p><strong class="Doctor">Doctor</strong>: I'm really sorry to hear that. Let's take things one at a time. About the hand pain that's likely due to nerve involvement from the cancer spreading. I'll adjust your pain medication and add a nerve pain reliever. Something like gabapentin may help ease that burning sensation.</p></div></td></tr><tr><td id="fragmentid_4"><div><p><strong class="Patient">Patient</strong>: Thank you. That pain has been unbearable at times.</p></div></td></tr><tr><td id="fragmentid_5"><div><p><strong class="Doctor">Doctor</strong>: I can imagine. Now, about the hallucinations are you seeing or hearing things? And how often does it happen?</p></div></td></tr><tr><td id="fragmentid_6"><div><p><strong class="Patient">Patient</strong>: Mostly at night. I sometimes see people in my room or hear voices calling my name. I know they're not real, but it's terrifying.</p></div></td></tr><tr><td id="fragmentid_7"><div><p><strong class="Doctor">Doctor</strong>: That sounds distressing. It could be a side effect of the high-dose opioids or just the progression of the illness. I'll refer you to our palliative care psychiatrist. Meanwhile, I'll reduce your opioid slightly and introduce a low dose of haloperidol. It should help manage the hallucinations.</p></div></td></tr><tr><td id="fragmentid_8"><div><p><strong class="Patient">Patient</strong>: Thank you, doctor. It's just been so hard. I feel like I'm losing control.</p></div></td></tr><tr><td id="fragmentid_9"><div><p><strong class="Doctor">Doctor</strong>: You're not alone, Mrs. Sharma. We're here to support you every step of the way. We'll keep monitoring and adjusting things to give you as much comfort and peace as possible.</p></div></td></tr><tr><td id="fragmentid_10"><div><p><strong class="Patient">Patient</strong>: I'm grateful for that, really.</p></div></td></tr></tbody>

Clinical Notes

Emergency Consult

Patient Identifier: Mrs. Sharma

Date of Visit: SESSION_DATE

Time of Visit: [Time of Visit]

Presenting Complaint (CC): Worsening left hand pain and hallucinations

History of Present Illness (HPI): Mrs. Sharma presents with worsening pain in her left hand, described as sharp, constant, and burning. She also reports experiencing hallucinations, mostly at night, where she sees people in her room or hears voices calling her name. She acknowledges these are not real but finds them terrifying. The pain is suspected to be due to nerve involvement from cancer spreading.

Review of Systems:

  • Neurological: Hallucinations (visual and auditory)
  • Musculoskeletal: Left hand pain

Physical Examination:

  • Neurological: No acute findings reported

Past Medical History:

  • Cancer

Family History:

  • Not discussed

Medications:

  • Opioids for pain management
  • Gabapentin for nerve pain
  • Haloperidol for hallucinations

Allergies:

  • None reported

Investigations:

  • None conducted during this visit

Labwork:

  • None reported

Triage Information:

  • Vital signs: [Record vital signs if available]
  • Pain score: [Record pain score if available]

Resuscitation and Stabilization Measures:

  • None required

Time-Sensitive Interventions:

  • Adjustment of pain medication and introduction of nerve pain reliever

Consultations and Notifications:

  • Referral to palliative care psychiatrist

Critical Findings:

  • None reported

Disposition:

  • Continue monitoring and adjusting treatment as needed

Follow-up Recommendations:

  • Follow-up with palliative care psychiatrist

Impression/Plan:

  • 1. Worsening left hand pain due to cancer:
    • Plan: Adjust pain medication and add gabapentin for nerve pain.
  • 2. Hallucinations:
    • Plan: Reduce opioid dosage and introduce low dose haloperidol. Refer to palliative care psychiatrist for further evaluation.
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